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T WELL 1 PUMP PERMIT <br /> ,N JOAQUIN COUNTY ENVIRONMENTAL HEALTI JErARTMENT 304 E WEBER-AVE V FL-STOCKTON CA 95202 - (209)468-3420 <br /> ION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ' EXPIRES 1 YEAR FROM DATE ISSUED <br /> Z / N , LVICIs <br /> f �2 `-f <br /> lOB ADDRESS / CITYIZIP y <br /> Q/2 -0- ' <br /> CROSS STREET �` ` PARCEL SIZE _LAND USE APPLICATION <br /> PHONE <br /> OWNER NAME � <br /> OWNER ADDRESS14,90 ��� rU CITYISTATEIZIP <br /> CONTRACTOR PHONE <br /> 4 CITYISTATEIZIP <br /> CONTRACTOR ADDRESS Lj <br /> r 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> 1 LICENSE ❑C-57 ❑C-61 ❑D-09 El Other NUMBER EXPIRATION DATE _ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br /> INTENDED USE oritesticlPrivate C]Irrigation/Agricultural D Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water Stem <br /> if different from owner: ater System Name ontact armor one um er _ <br /> R TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> #of borings ❑Geotechnical #of borings <br /> E3 Monitoring Well(s) �#of wells ❑Soil Boring(s) C <br /> XOut-Of-Service Well 9—j" ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair 4 <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable-Tool ❑Push Point CI Other (� <br /> L Proposed Well Depth . ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter t/ <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seat Depth ft ©Neat Cement(94 lb bag 15-10 gal waler) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Contractor ❑ Other <br /> ❑Concrete Pedestal D' nsions: idth ft Length ft Thick in Cl Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Tur er ne O HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE REP RED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, 5 A LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED L[CENSE IS <br /> CURRENT AND ACTIVE WITH THE LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NI UM 24 H t ADVANC AO�E REQUIRED FOR INSPECTION <br /> Ir.ti <br /> 'l SIGNED 4TITLE DATE <br /> � .ttt <br /> 7 gin <br /> t - <br /> • <br /> F <br /> AN JO No liv CC U <br /> iPA <br /> IT <br /> E <br /> DEPARTMENT USE ONI Y <br /> I_ Area _ Employee ID# f <br /> Aprllcahon Accepted By Date C7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructedyl'�ell Depth �l f <br /> COMMENT e U[� <br /> PE SC Received hec Amount Date Permit! Invoice# WeII ID# <br /> Codes Info By r.2th Remitted Service Request Cke # <br /> re <br /> rl <br /> fr ti °1 Z ts=' b <br /> ri <br /> WELL PUMP PERMIT <br /> � EHD 43-02-006 <br /> 112712005 <br />